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Rehospitalizations: Preventable and Costly
Partnering with a Care Manager
Success Story: A Rewarding Relationship
Rehospitalizations: Preventable and Costly
by Rona S. Bartelstone, LCSW, BCD, CMC, C-ASWCM
Did you know that almost 20% of people on Medicare are rehospitalized within 30 days of a hospital discharge? And 60 days post-discharge almost 30% of this same population are readmitted to the hospital. (Jencks, Stephen F, et.al. NEJM 360;14. April 2009)
These are huge numbers and should pose a concern to physicians and family caregivers. For older adults, being in the hospital is often a risk itself. There are risks of infection, risks of changes in mental status (especially if there is already some cognitive changes), and concerns for family caregivers, who themselves are older, or missing work to care for their loved one.
In the same study cited above, it was also discovered that 50% of the patients who were readmitted to the hospital within 30 days, had not seen an outpatient physician. This raises further concerns about the ability of people over the age of 65 (hence Medicare eligible) to self direct their care and assure compliance with hospital discharge plans, which usually call for follow up with a primary or specialty physician.
This is not to say that people over the age of 65 are not reliable for their own care. Instead, these statistics mean that the health care system needs to do a better job in following older patients across transitions of care. The very fact of being hospitalized creates a loss of energy, concentration and even emotional trauma. Recovery often takes longer as we age. Challenges to meet everyday demands can seem insurmountable. Getting back to the doctor may not seem as important as getting groceries, medications, therapy and rest. Additionally, in some areas of the country, just getting an appointment with one’s doctor can take a month.
With health care reform on the horizon, hospitals will need to consider improved relationships with those community-based organizations that provide long term care in the home setting. Most hospitals have relationships with Medicare Certified Home Health Agencies. What most people don’t realize is that Medicare does not pay for long-term care. So when a Medicare agency is recommended, patients, families and caregivers need to realize that this is time limited care only. Usually Medicare home care is only provided for several weeks. Then what happens?
For people who need care on a more continuous basis, the most typical level of care is for someone who is there to provide safety, medication reminders, assistance with bathing, dressing and toileting. These people often need help with things such as shopping, meal preparation, errands and doctor appointments, as well. Additionally, older adults often need emotional support to cope with their changes in function and an advocate to assure that they do get the follow up care that is so critical to recovery, without rehospitalization.
This is part of the reason that SeniorBridge Care Managers work in teams. It is helpful to have staff who have expertise in a diverse array of care needs. So that while one Care Manager might have greater expertise in the medication, treatment and therapeutic aspects of recovery, the other will be focusing on the emotional needs of the patient and family, while making follow up appointments for the patient.
Preventable rehospitalizations will not only make life more comfortable for the older adult and their family, it will also save millions in unnecessary Medicare expenditures. Perhaps those exploring health care reform should take a look at the SeniorBridge model of care across the continuum.
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Partnering with a Care Manager
by Rona S. Bartelstone, LCSW, BCD, CMC, C-ASWCM
Traditionally, physicians have been the point person for primary care. But with diseases today being mostly chronic illnesses requiring a range of health, social, emotional, environmental and physical services in addition to medical care, private care management has emerged as a leader in guiding families through the caregiving process.
A successful partnership between the care manager and the family, as illustrated below, facilitates the coordination of appropriate care, at the appropriate time, in the right setting and in accordance with individual needs and resources.
Care Management at Work
Living away from their family, Mr. and Mrs. Chasser (not their real name) were beginning to deal with multiple care decisions. They were a worldly couple who had saved enough money to meet their retirement needs.
Though relatively healthy, Mr. Chasser was beginning to experience some memory loss and asked his wife to take over the daily money management. Mrs. Chasser, 80, had a heart condition as well as osteoporosis; she was becoming increasingly anxious that her husband was becoming senile. Mrs. Chasser had never been responsible for money management, investments or legal issues and was afraid to ask her husband for guidance, fearing she might upset him.
After a trip to visit their grandchildren, Mrs. Chasser had a stroke, causing her to become weak and unable to speak. Although she would regain some of her mobility and speech, she would never be as active again. While Mrs. Chasser was in the hospital and rehabilitation center, Mr. Chasser realized he could not manage at home alone. He was unable to take care of the shopping, meal preparation, laundry or housekeeping. He also had difficulty dressing himself and frequently became frightened, knocking on neighbors’ doors at all hours.
A concerned neighbor called the couple’s son, Brian, who was unaware of the extent of his father’s memory loss and his inability to manage at home alone. When his mother was going to be discharged from the hospital to a long term care facility for rehabilitation Brian flew in to visit his parents. Upon arriving at their home, Brian found his father sitting in the dark crying because he could not remember when his son was coming and he thought his wife had already been moved, though he could not remember where. In the unkempt house, Brian found no food and dirty clothes; he suspected that his father hadn’t bathed in several days.
While a hospital social worker was able to assist Brian with his mother’s care, she was unable to help with his father because he was not a patient. She suggested hiring a private care manager who would be able to help coordinate the care of both parents. A care manager could also help integrate the different services and payer sources to provide the optimal plan.
Brian hired a care manager who soon discovered there were several levels of need and sources of support. After a comprehensive assessment, she helped Brian determine the best short term and long term plan of care for his parents.
At the rehab facility, Mrs. Chasser’s care was covered by Medicare and supplemental insurance policies for two weeks. If more care was deemed necessary, the couple’s long term care policy would cover the cost.
Mr. Chasser needed extensive care as well. The care manager felt his cognitive losses and anxiety were being exacerbated by the stress of his wife’s illness. She arranged for a complete neurological and psychiatric work-up, resulting in a diagnosis of probable Alzheimer’s disease. The diagnosis qualified Mr. Chasser for home care benefits under his long term care policy.
The care manager placed a temporary, 24-hour aide in the home. She also arranged community services for Mr. Chasser, including a daycare program with stimulation and socialization, and brought a medication dispenser to the Chassers’ home to assure compliance with medication routines. Grab bars and a shower seat were added to the bathroom and a personal emergency response system (ERS) was installed that could eventually reduce the hours the aide was needed. The care manager worked with Brian to help him understand how the long term care policy would work and how to allocate its use so that the pool of funds would not be depleted too quickly. This was a particular concern since Mr. Chasser could live with his dementing illness for many years.
The care manager worked with the family to bring Mrs. Chasser home after rehab. With the ERS in place, the couple could be alone for 14 hours each day. Gradually, as Mrs. Chasser became more frail and Mr. Chasser more forgetful, 24-hour care was reinstated. Eighteen months later, when Mrs. Chasser died, the care manager helped support Mr. Chasser through his grief and eventually helped move him to an Alzheimer’s-specific assisted living facility. After a brief adjustment, he began to flourish in the new residence.
Brian was grateful to the care manager for helping his family navigate a complex, fragmented system of health and social services. He also was relieved that in spite of using his parents’ financial resources to pay for their care, there were still financial resources that would help pay for his children’s college education. In fact, a result of the heart-wrenching experience, Brian began to work on his own financial, insurance and legal plans.
A Successful Partnership
The entire Chasser family benefited from the partnership with their care manager. Brian was able to visit his parents as planned, instead of always in a crisis mode. Mr. and Mrs. Chasser were able to be cared for in their own home using a combination of private insurance, community resources, entitlement programs and emotional support from the care manager. The physician, who received regular reports from the care manager, was confident that his plan of care would be carried out in the home to assure the best treatment possible in a safe environment. And finally, when it was appropriate, Mr. Chasser was able to move into assisted living that catered to his specific needs.
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Success Story: A Rewarding Relationship
by Marilyn Goldman, LCSW-C, GCM
Mrs. L, 89, is a widow with a history of depression, anxiety and a moderate level of dementia. She also has a history of breast cancer (which has been in remission for several years) and uses a cane due to a previous break of the femur.
For five years, Mrs. L, who used to be very socially active, has been living in an independent living facility apartment. The facility offers weekly activities and outings as well as in-house physical therapy.
Mrs. L has two very supportive daughters, one who lives locally and assists with activities of daily living, and one out of town who helps with planning and coordinating. She also has a large extended family.
After Mrs. L had a minor car accident and decided to stop driving, her daughters felt she would benefit from additional help. They learned about SeniorBridge through the company’s website.
The daughters informed SeniorBridge that their mother was fearful of becoming like her brother who had dementia. She was often anxious and berated herself for forgetting simple things. In addition, she needed constant prompting to accomplish basic activities and to engage in social activities. More and more, she was becoming socially isolated.
SeniorBridge began caregiver services 16 hours weekly, assisting Mrs. L with getting up in the mornings and reminding her to take her medications and to eat. The caregiver also assisted with socialization, engaging Mrs. L in a knitting project, and accompanying her to medical appointments and to the grocery store. The caregiver also read to Mrs. L, walked her to dinner in the facility’s dining room, took her to local community events and helped address her spiritual needs.
For Mrs. L, the relationship has become therapeutic. Despite being introverted, she now tells her Care Manager about her fears, allowing the Care Manager to provide emotional support.
The Care Manager communicates regularly with the daughters on Mrs. L’s progress as well as to follow-up on doctor appointments. She was able to get a physical therapist to come into the home and she also has had Mrs. L’s medications evaluated.
In addition, the Care Manager provides guidance to the SeniorBridge caregiver on beneficial activities and effective ways to communicate with Mrs. L. She has developed a "Therapeutic Activity Log" to provide daily activity reports.
Mrs. L continues to live in her apartment. While her interactions and activities have decreased over time, she is accepting increased caregiver services and Care Management visits. Her physical issues are being addressed successfully with in-home therapy and she takes her medications as prescribed with verbal prompting. Recognizing Mrs. L’s love for classical music, the Care Manager is looking into the possibility of a music therapist.
All around, it has been a rewarding relationship.
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